Published by Licence of the Board of Trade under the " Trading with the Enemy Amendment Act, 1916." DEMENTIA PRECOX AND PARAPHRENIA BY Professor EMIL KRAEPELIN of Munich TRANSLATED BY R. MARY BARCLAY, M.A., M.B. From the Eighth German Edition of the " Text-Book of Psychiatry,' vol. iii., part ii., section on the Endogenous Dementias EDITED BY GEORGE M. ROBERTSON, M.D, F.R.C.P. (Edin.) Lecturer on Mental Diseases in the University of Edinburgh and Physician to the Royal Asylum, Morningside EDINBURGH E. & S. LIVINGSTONE 17 TEVIOT PLACE 1919 EDITOR'S PREFACE. KS'i'^d Dementia Pr/ECOX has excited more interest and speculation than any other form of insanity in our time, with the possible exception of general paralysis of the insane. I therefore value highly the usefulness of the work that Dr Mary Barclay has done in thus bringing before English-speaking physicians a faithful 'translation of the views of Professor Kraepelin, who is the recognised authority on this subject. In no country has there been less inclination to accept his doctrines without qualification than in this, but so important are they, that every physician of the mind, who would keep himself abreast of modern clinical research, must be familiar with them. The present work therefore supplies a want in giving in an accessible form the complete and latest account of this subject by Professor Kraepelin. In addition, there is no other publication in the English language which deals solely with dementia praecox in all its various aspects. Professor Kraepelin informs us that he got the starting point which led to dementia praecox being regarded by him as a distinct disease, in the year 1896. He admits "that Clouston also, who spoke of an ' adolescent insanity,' had evidently before everything dementia praecox in view, though he did not yet separate it from manic-depressive cases, which likewise often begin about this time." The identity of Clouston's "secondary dementia of adolescence" with the chief forms of dementia precox is quite apparent to anyone reading the remarkable address on dementia which he delivered in 1888 when President of the Medico-Psychological Association. While, however, Sir Thomas Clouston regarded some of his cases of adolescent insanity as being of an un- favourable type which often ended in secondary dementia, Professor Kraepelin would regard these very cases, from their initial symptoms onward, as being examples of a distinct form of disease, namely dementia praecox. This situation therefore recalls in an interesting manner the circumstances connected with the discovery of general paralysis of the insane. Esquirol and his pupils had for seventeen years been observing cases of " insanity complicated with paralysis," when Bayle, in 1822, boldly asserted that the symptoms of this clinical condition were those of a separate and definite disease. This hypothesis has proved true ; is it too soon yet to say the same of the former ? ii EDITOR'S PREFACE Professor Kraepelin's task in depicting the characteristic features of dementia praicox has not been an easy one, and even now he has not reached finaHty in his opinions. He is not satisfied with his deHmitation of its boundaries, nor with all the sub-divisions which he has created, though he believes that his main thesis has been substantiated. Neither terminal dementia nor precocity is, however, an essential element of the clinical picture, though his reluctance to discard the former is very evident, and this masterly summary has been as a matter of fact prepared solely from observation of cases which actually became demented. Now that general paralysis of the insane, after a century of observation and research, has yielded up most of its secrets, by far the most important practical problem facing the psychiatrist and the community, in the domain of mental hygiene, is that of dementia pra^cox. The patients suffering from this disease form the major part of the inmates of our mental hospitals. The heavy financial burden imposed upon the public for the treatment of the insane, resolves itself therefore very largely into the outlays needed for the lifelong care of the almost hopeless victims of this disorder. More- over, as the disease does not directly cause death, and as such patients lead protected lives and live long, they tend to accumulate. They thus form the chief reason for the periodical necessity of enlarging our mental hospitals, and of erecting new ones. Could a study of the causes and treatment of this disorder result in its prevention or diminution, its cure or alleviation, a practical benefit to society of the most direct and valuable kind would be conferred. Such an enquiry should have the support of the Ministry of Health as this disease costs the State more than any other. How to avert this dementia continues to be the cardinal problem of psxxhiatry. It is hoped that the publication of this translation will stimulate the interest of English-speaking physicians in these peculiar states of mental enfeeblemient, promote further clinical observation and research, and lead to greater accuracy of diagnosis and prognosis, with a better understanding of the nature of the disease. GEORGE M. ROBERTSON. University of Edinburgh, July 1919. TRANSLATOR'S PREFACE. As the aim of this translation is to bring the views of Professor Kraepelin, of Munich, on dementia praecox before the English-speaking members of the medical profession who may not be intimately acquainted with German, I have made it as literal as seemed consistent with readable English, Professor Kraepelin's Psychiatry is the leading German text- book on disorders of the mind, and I therefore willingly- acceded to the wish of Dr George Robertson to make a complete translation of the section on dementia praecox. This special disease still requires much elucidation, and in its study medical practitioners, educationalists, and crimin- ologists may well work together. It is especially on the educational side that Professor Kraepelin's observations or investigations appear to be deficient. It should not be difficult in this country to collect the required facts relating to individual cases, and to a certain extent this is being done already. W^hen these facts are classified, much benefit should accrue to education, medical advancement, and the public welfare. To Dr George Robertson I have to express my thanks for many useful suggestions, and to Dr W'alker for the unwearying care with which he has revised the proofs. R. MARY BARCLAY. Edinburgh, July 1919. CONTENTS. Preface ....... Introduction—THE ENDOGENOUS DEMENTIAS I. DEMENTIA PR.ECOX II. PSYCHIC SYMPTOMS Perception ..... Attention ..... Hallucinations (thoughts heard, thought influence) Orientation ..... Consciousness ..... Memory ..... Retention (pseudo-memories) . Train of thought (loss of mental activity) Association Stereotypy Paralogia, evasion Constraint Mental efficiency Judgment Delusions V.'-'^motional dulness, ataxia of the feelings V^-Weakening of volitional impulse Automatic obedience (catalepsy, echolalia, echopraxis) Impulsive actions .... Catatonic excitement .... Stereotyped attitudes and movements Mannerisms ..... Parabulia ..... V^^-'^egativism (autism, stupor) . \^ Personality ..... Practical efficiency .... L^Iovements of expression Incoherence ..... Stereotypy (verbigeration) V^ Negativism (mutism, evasion) Derailments in word-finding . Paraphasia ..... Neologisms ..... Akataphasia ..... Syntax ..... Derailments in train of thought III. GENERAL PSYCHIC CLINICAL PICTURE ^, Blunting of emotions .... Intrapsychic ataxia .... CONTENTS Chap. Page IV. BODILY SYMPTOMS Headaches Pupillary disorders Tendon reflexes Muscular movements Seizures Grimacing Aphasia Vasomotor disorders Blood -pressure Respiration Secretion of saliva Temperature . Menses Blood-picture . Metabolism Changes in the thyroid Sleep . Nourishment . Weight V. CLINICAL FORMS Dementia praecox simplex Silly dementia priecox, hebeph:renia Simple depressive dementia p E«cox, stupor Delusional depressive dementia priecox Circular dementia praecox Agitated dementia prrecox Periodic dementia praecox Catatonia* excitement, stupor (melancholia attonita) Paranoid dementia praecox, gravis Paranoid dementia prs^cox, mitis Confusional speech dementia pr^ecox, schizophasia VI. COURSE, REMISSIONS VII. ISSUE . Recovery, recovery with defect Simple weakmindedness Hallucinatory weakmindedness Paranoid weakmindedness Drivelling dementia Dull dementia Silly dementia Manneristic dementia Negativistic dementia Prognostic indications Death, mortality VIII. MORBID ANATOMY Cell morbidity Changes in glia CONTENTS Chaf. Atrophy of medullary fibres .... Relations of the changes in the cortex to the clinical picture IX. FREQUENCY, CAUSES Time of life Engrafted hebephrenia Idiocy Dementia prcecocissima Late catatonias Dementia tardiva Sex General conditions of life Hereditary predisposition Injury to the germ, alcoholism, syphilis Personal idiosyncrasy . External causes—over-exertion, infection, syphilis, head injuries, alcohol, imprisonment, reproduction Sexual life ..... Auto-intoxication .... Freudian complexes .... DELIMITATION .... Paranoid forms .... Catatonia ..... Late catatonias .... Periodic forms .... Confusion of speech .... XI. DIAGNOSIS ..... Catatonic symptoms .... Psychopathic states .... Imbecility and idiocy .... Manic-depressive insanity Hysteria ..... Psychogenic psychoses Dissimulation ..... Epilepsy ..... Paralysis ..... Amentia (confusional or delirious insanity) Cerebral syphilis .... Paranoid diseases .... XII.